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Does Medicare Cover Botox for Migraines?
Aug 13, 2021

Does Medicare Cover Botox for Migraines?

Medicare may cover Botox injections if you experience chronic migraines.

A migraine is a type of headache that can cause severe throbbing pain or a pulsing sensation, often accompanied by nausea, vomiting, and sensitivity to light and sound. Migraines can last for hours or even days, and sometimes the pain can be so severe it interferes with your daily life.

In 2010, Botox was approved for adults as a treatment for chronic migraines. This means you have a history of migraine headaches or have headaches on most days of the month (8 of which are a migraine). Botox is a neurotoxin that helps block chemicals called neurotransmitters that carry pain signals from your brain. This keeps them from getting to the nerve endings around your head and neck, which cause migraines.

In some cases, Medicare may cover Botox injections for treating migraines. However, there are typically guidelines for receiving injections and a cost associated with them, so it's important to do your research and work with your doctor to ensure your treatment is covered.

Is Botox covered by Medicare?

While Botox is not covered by Medicare for cosmetic reasons, it may be if it's used as a medical treatment.

For example, Botox is not covered to address wrinkles, but would be if it's considered medically necessary when used to prevent or treat a health condition. Medicare will cover these treatments if it's recommended by your doctor for one of a few conditions, including chronic, severe migraines.

Coverage may only be allowed for patients with chronic daily headaches, meaning you have headaches more than 15 days in a month, typically for a duration of four or more hours, for at least three months. Eight of the 15 days must meet criteria for a migraine. You must also prove significant disability due to the headaches, and that other treatments must have failed.

To continue Botox therapy, you must demonstrate a significant decrease in the number of headaches you get, as well as an improvement of function upon receiving the injections.

Other conditions treated by Botox that are covered Medicare include severe neck spasms, overactive bladder, overactive sweat glands, crossed eyes, or TMJ disorder.

How to get coverage for a Botox procedure

While coverage is not always guaranteed, there are a few steps you should take to help ensure your Botox procedure is covered:

  • Have your doctor (who must be Medicare-approved) submit a request to Medicare, outlining why Botox is medically necessary for your migraines
  • Send records of your condition to Medicare, including proof of your diagnosis, documented symptoms, and documentation that at least two other forms of treatment have failed

Talk with your doctor about the documentation and information you'll need to provide, and call Medicare directly to ensure all your bases are covered. Ask about any specific documents they may need to see or if there are any other steps you must take.

If you have a Part D prescription drug plan or a Medicare Advantage (Part C) plan, your coverage may differ. Contact your plan to check if Botox is on your formulary and how much the cost would be.

How much does Botox cost?

Your cost depends on the number of sessions you need, as well as how much of the drug is required for each session. However, treatment could cost $300 to $600 each.

In most cases, Medicare would pay 80% of the cost, and you'd be responsible for the other 20%. Keep in mind that Botox is usually only a temporary fix, and most people need treatment again after a period of time. You'd pay 20% out-of-pocket for each treatment.

To get help with paying these costs, you could purchase a Medicare Supplement (Medigap) plan, which helps fill in the gaps of Original Medicare. These plans may pay for the co-insurance or co-payment costs you'd have for this procedure. However, Medigap plans do not cover your out-of-pocket Part D costs. They only help pay for services covered by Original Medicare. In addition, if you have an Advantage plan, you cannot also join a Medicare Supplement plan.

Even if Medicare denies your coverage, you can still get Botox injections. You'll just have to pay 100% of the costs out-of-pocket.

When to see a doctor for migraines

Most people don’t to the doctor if they are experiencing a migraine. However, if you have them often, you should keep track of when they hit, what you were doing, and how you treated it. Show this list to your doctor to discuss your options.

You should see your doctor immediately, or even go to the emergency room, if you experience:

  • An abrupt, severe headache like a thunderclap
  • Headache with fever, stiff neck, confusion, seizures, double vision, numbness, or weakness
  • Headache after a head injury
  • A chronic headache that gets worse by coughing, exertion, straining, or moving suddenly
  • New headache pain after age 50

These could be signs of a more serious medical problem, such as a stroke.

Are you looking for Medicare Part D coverage?

If you're ready to join a Medicare Part D prescription drug plan OR a Medicare Advantage Prescription Drug plan, call us toll-free to learn more about the plans available in your area. Or, use our Plan Finder tool to review your options. Just enter your zip code and medications to start reviewing Part D plans in your area.

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